Medical Students’ Perceptions of Their Learning Environment, Well-Being and Academic Self-Concept

Topi Litmanen¹, Sofie M. M. Loyens², Kirsi Sjöblom¹, Kirsti Lonka¹

¹Research Group of Educational Psychology, Department of Teacher Education, University of Helsinki, Helsinki, Finland.
²Department of Psychology, Erasmus University Rotterdam, Rotterdam, The Netherlands.

DOI: 10.4236/ce.2014.521207                

Abstract

This study investigated medical students’ perceptions of their learning environment and how these related to well-being in terms of experienced exhaustion and losing interest in personal studies. The goal was to also examine whether students’ perceptions and experiences of well-being related to their academic self-concept. Experiences were compared between lecture-based learning (LBL) and problem-based learning (PBL) environments. The MED NORD questionnaire was used to measure students’ experiences of their learning environment, experienced well-being (i.e. exhaustion and lack of interest) and academic self-concept. A total of 610 students participated. Structural equation modelling was used to investigate relationships between the variables under study. A cross-sectional design was used to compare experiences between different medical schools. Worry about future workload was found to positively relate to exhaustion, whereas worry and study satisfaction both negatively related to lack of interest. Experienced high workload related to both exhaustion and lack of interest. In turn, lack of interest was negatively related to academic self-concept, whereas exhaustion was positively related to it. PBL students reported higher levels of worry concerning future workloads, but they also experienced receiving more feedback. In addition, novice PBL students experienced higher levels of exhaustion and better academic self-concept than LBL students. No such differences were found between students in the clinical phase. Lack of interest concerning personal studies appeared to be more unfavourable than experiences of exhaustion, because the former was related to low academic self-concept. The PBL environment appeared challenging, but only during the first years of study.

Keywords

Problem Based Learning, Undergraduate Medical Education, Structural Equation Modelling, Student Perception, Well-Being

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Abdulghani, H. M., Al-Drees, A. A., Khalil, M. S., Ahmad, F., Ponnamperuma, G. G., & Amin, Z. (2014). What Factors Determine Academic Achievement in High Achieving Undergraduate Medical Students? A Qualitative Study. Medical Teacher, 36, S43-S48. http://dx.doi.org/10.3109/0142159X.2014.886011
[2]	Benbassat, J. (2014). Changes in Wellbeing and Professional Values among Medical Undergraduate Students: A Narrative Review of the Literature. Advances in Health Sciences Education, 19, 597-610. http://dx.doi.org/10.1007/s10459-014-9500-1
[3]	Bentler, P. (1990). Comparative Fit Indexes in Structural Models. Psychological Bulletin, 107, 238-246. http://dx.doi.org/10.1037/0033-2909.107.2.238
[4]	Bong, M., & Skaalvik, E. M. (2003). Academic Self-Concept and Self-Efficacy: How Different Are They Really? Educational Psychology Review, 15, 1-40. http://dx.doi.org/10.1023/A:1021302408382
[5]	Browne, M. W., & Cudeck, R. (1993). Multifaceted Conceptions of Fit in Structural Equation Models. In K. A. Bollen, & J. S. Long (Eds.), Testing Structural Equation Models (pp. 137-162). Newbury Park, CA: Sage.
[6]	Camp, D. L., Hollingsworth, M. A., Zaccaro, D. J., Cariaga-Lo, L. D., & Richards, B. F. (1994). Does a Problem-Based Learning Curriculum Affect Depression in Medical Students? Academic Medicine: Journal of the Association of American Medical Colleges, 69, S25-S27. http://dx.doi.org/10.1097/00001888-199410000-00031
[7]	Cohen, J. (1988). Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum.
[8]	Dahlin, M. (2007). Future Doctors: Mental Distress during Medical Education: Cross-Sectional and Longitudinal Studies. Stockholm: Karolinska University Press.
[9]	Dahlin, M., Joneborg, N., & Runeson, B. (2005). Stress and Depression among Medical Students: A Cross-Sectional Study. Medical Education, 39, 594-604. http://dx.doi.org/10.1111/j.1365-2929.2005.02176.x
[10]	Dahlin, M., Fjell, J., & Runeson, B. (2010). Factors at Medical School and Work Related to Exhaustion among Physicians in Their First Postgraduate Year. Nordic Journal of Psychiatry, 64, 402-408. http://dx.doi.org/10.3109/08039481003759219
[11]	Dyrbye, L. N., Thomas, M. R., Harper, W., Massie Jr., F. S., Power, D. V., Eacker, A., Szydlo, D. W., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2009). The Learning Environment and Medical Student Burnout: A Multicentre Study. Medical Education, 43, 274-282. http://dx.doi.org/10.1111/j.1365-2923.2008.03282.x
[12]	Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic Review of Depression, Anxiety, and Other Indicators of Psychological Distress among U.S. and Canadian Medical Students. Academic Medicine, 81, 354-373. http://dx.doi.org/10.1097/00001888-200604000-00009
[13]	Elnicki, D. M., Curry, R. H., Fagan, M., Friedman, E., Jacobson, E., Loftus, T., Ogden, P., Pangaro, L., Papadakis, M., Szauter, K., Wallach, P., & Linger, B. (2002). Medical Students’ Perspectives on and Responses to Abuse during the Internal Medicine Clerkship. Teaching and Learning in Medicine, 14, 92-97. http://dx.doi.org/10.1207/S15328015TLM1402_05
[14]	Fidell, L. S., & Tabachnick, B. G. (2007). Using Multivariate Statistics. Boston, MA: Pearson Allyn and Bacon.
[15]	Fraser, B. J. (1998). Science Learning Environments: Assessment, Effects and Determinants. In B. J. Fraser, & K. G. Tobin (Eds.), International Handbook of Science Education (pp. 527-561). Dordrecht: Kluwer Academic Publishers. http://dx.doi.org/10.1007/978-94-011-4940-2_31
[16]	Genn, J. M. (2001). AMEE Medical Education Guide No. 23 (Part 2): Curriculum, Environment, Climate, Quality and Change in Medical Education—A Unifying Perspective. Medical Teacher, 23, 445-454.
[17]	Guthrie, E. A., Black, D., Shaw, C. M., Hamilton, J., Creed, F. H., & Tomenson, B. (1995). Embarking upon a Medical Career: Psychological Morbidity in First Year Medical Students. Medical Education, 29, 337-341. http://dx.doi.org/10.1111/j.1365-2923.1995.tb00022.x
[18]	Hammond, S. M., O’Rourke, M., Kelly, M., Bennett, D., & O’Flynn, S. (2012). A Psychometric Appraisal of the DREEM. BMC Medical Education, 12, 2. http://dx.doi.org/10.1186/1472-6920-12-2
[19]	Hancock, G. R., & Mueller, R. O. (2001). Rethinking Construct Reliability within Latent Variable Systems. In R. Cudeck, S. du Toit, & D. S?rbom (Eds.), Structural Equation Modeling: Present und Future—A Festschrift in Honor of Karl Joreskog (pp. 195-216). Lincolnwood, IL: Scientific Software International.
[20]	Hansford, B. C., & Hattie, J. A. (1982). The Relationship between Self and Achievement/Performance Measures. Review of Educational Research, 52, 123-142. http://dx.doi.org/10.3102/00346543052001123
[21]	Kember, D., & Leung, D. Y. P. (2006). Characterising a Teaching and Learning Environment Conducive to Making Demands on Students While Not Making Their Workload Excessive. Studies in Higher Education, 31, 185-198. http://dx.doi.org/10.1080/03075070600572074
[22]	Kiessling, C., Schubert, B., Scheffner, D., & Burger, W. (2004). First Year Medical Students’ Perceptions of Stress and Support: A Comparison between Reformed and Traditional Track Curricula. Medical Education, 38, 504-509. http://dx.doi.org/10.1046/j.1365-2929.2004.01816.x
[23]	Kline, R. B. (2005). Principles and Practice of Structural Equation Modeling (2nd ed.). New York: Guilford Press.
[24]	Krakowski, A. J. (1982). Stress and the Practice of Medicine—The Myth and Reality. Journal of Psychosomatic Research, 26, 91-98. http://dx.doi.org/10.1016/0022-3999(82)90068-X
[25]	Lewis, A. D., Menezes, D. A., McDermott, H. E., Hibbert, L. J., Brennan, S. L., Ross, E. E., & Jones, L. A. (2009). A Comparison of Course-Related Stressors in Undergraduate Problem-Based Learning (PBL) versus Non-PBL Medical Programmes. BMC Medical Education, 9, 60. http://dx.doi.org/10.1186/1472-6920-9-60
[26]	Lindblom-Yl?nne, S., & Lonka, K. (2000). Interaction between Learning Environment and Expert Learning. Lifelong Learning in Europe, 5, 90-97.
[27]	Lonka, K., Sharafi, P., Karlgren, K., Masiello, I., Nieminen, J., Birgegard, G., & Josephson, A. (2008). MED NORD—A Tool for Measuring Medical Students’ Well-Being and Study Orientations. Medical Teacher, 30, 72-79. http://dx.doi.org/10.1080/01421590701769555
[28]	Loyens, S. M. M., Rikers, R. M. J. P., & Schmidt, H. G. (2009). Students’ Conceptions of Constructivist Learning in Different Programme Years and Different Learning Environments. British Journal of Educational Psychology, 79, 501-514. http://dx.doi.org/10.1348/000709908X378117
[29]	Ma, X., & Kishor, N. (1997). Attitude toward Self, Social Factors, and Achievement in Mathematics: A Meta-Analytic Review. Educational Psychology Review, 9, 89-120. http://dx.doi.org/10.1023/A:1024785812050
[30]	M?kinen, J., Olkinuora, E., & Lonka, K. (2004). Students at Risk: Students’ General Study Orientations and Abandoning/Prolonging the Course of Studies. Higher Education: The International Journal of Higher Education and Educational Planning, 48, 173-188. http://dx.doi.org/10.1023/B:HIGH.0000034312.79289.ab
[31]	Marsh, H. W. (1987). The Big-Fish-Little-Pond Effect on Academic Self-Concept. Journal of Educational Psychology, 79, 280-295. http://dx.doi.org/10.1037/0022-0663.79.3.280
[32]	Maslach, C., & Jackson, S. E. (1981). The Measurement of Experienced Burnout. Journal of Occupational Behaviour, 2, 99-113.
[33]	Miles, S., Swift, L., & Leinster, S. J. (2012). The Dundee Ready Education Environment Measure (DREEM): A Review of Its Adoption and Use. Medical Teacher, 34, e620-e634. http://dx.doi.org/10.3109/0142159X.2012.668625
[34]	Moffat, K. J., McConnachie, A., Ross, S., & Morrison, J. M. (2004). First Year Medical Student Stress and Coping in a Problem-Based Learning Medical Curriculum. Medical Education, 38, 482-491. http://dx.doi.org/10.1046/j.1365-2929.2004.01814.x
[35]	Nieminen, J. (2011). Dimensions of University Student Learning in Medicine and Pharmacy. Helsinki: University of Helsinki.
[36]	Pekrun, R. (2006). The Control-Value Theory of Achievement Emotions: Assumptions, Corollaries, and Implications for Educational Research and Practice. Educational Psychology Review, 18, 315-341. http://dx.doi.org/10.1007/s10648-006-9029-9
[37]	Roff, S. (2005). The Dundee Ready Educational Environment Measure (DREEM)—a Generic Instrument for Measuring Students’ Perceptions of Undergraduate Health Professions Curricula. Medical Teacher, 27, 322-325. http://dx.doi.org/10.1080/01421590500151054
[38]	Roff, S., McAleer, S., Harden, R. M., Al-Qahtani, M., Ahmed, A. U., Deza, H., Groenen, G., & Primparyon, P. (1997). Development and Validation of the Dundee Ready Education Environment Measure (DREEM). Medical Teacher, 19, 295-299. http://dx.doi.org/10.3109/01421599709034208
[39]	Salanova, M., Schaufeli, W., Martínez, I., & Bresó, E. (2010). How Obstacles and Facilitators Predict Academic Performance: The Mediating Role of Study Burnout and Engagement. Anxiety, Stress & Coping, 23, 53-70. http://dx.doi.org/10.1080/10615800802609965
[40]	Salmela-Aro, K., & Kunttu, K. (2010). Study Burnout and Engagement in Higher Education. Unterrichtswissenschaft, 38, 318-333.
[41]	Salmela-Aro, K., Tolvanen, A., & Nurmi, J. (2009). Achievement Strategies during University Studies Predict Early Career Burnout and Engagement. Journal of Vocational Behavior, 75, 162-172. http://dx.doi.org/10.1016/j.jvb.2009.03.009
[42]	Schmidt, H. G. (1983). Problem-Based Learning: Rationale and Description. Medical Education, 17, 11-16. http://dx.doi.org/10.1111/j.1365-2923.1983.tb01086.x
[43]	Schmidt, H. G., Cohen-Schotanus, J., & Arends, L. R. (2009). Impact of Problem-Based, Active Learning on Graduation Rates for 10 Generations of Dutch Medical Students. Medical Education, 43, 211-218. http://dx.doi.org/10.1111/j.1365-2923.2008.03287.x
[44]	Schreiber, J. B., Nora, A., Stage, F. K., Barlow, E. A., & King, J. (2006). Reporting Structural Equation Modeling and Confirmatory Factor Analysis Results: A Review. Journal of Educational Research, 99, 323-338. http://dx.doi.org/10.3200/JOER.99.6.323-338
[45]	Shanafelt, T. D., Sloan, J. A., & Habermann, T. M. (2003). The Well-Being of Physicians. The American Journal of Medicine, 114, 513-519. http://dx.doi.org/10.1016/S0002-9343(03)00117-7
[46]	Skaalvik, E. M. (1997). Self-Enhancing and Self-Defeating Ego Orientation: Relations with Task and Avoidance Orientation, Achievement, Self-Perceptions, and Anxiety. Journal of Educational Psychology, 89, 71-81. http://dx.doi.org/10.1037/0022-0663.89.1.71
[47]	Skaalvik, E. M., & Rankin, R. J. (1995). A Test of the Internal/External Frame of Reference Model at Different Levels of Math and Verbal Self-Perception. American Educational Research Journal, 32, 161-184. http://dx.doi.org/10.3102/00028312032001161
[48]	Stewart, S. M., Lam, T. H., Betson, C. L., Wong, C. M., & Wong, A. M. (1999). A Prospective Analysis of Stress and Academic Performance in the First Two Years of Medical School. Medical Education, 33, 243-250. http://dx.doi.org/10.1046/j.1365-2923.1999.00294.x
[49]	Stubb, J., Pyhältö, K., & Lonka, K. (2012). The Experienced Meaning of Working with a PhD Thesis. Scandinavian Journal of Educational Research, 56, 439-456. http://dx.doi.org/10.1080/00313831.2011.599422
[50]	Taris, T. W. (2006). Is There a Relationship between Burnout and Objective Performance? A Critical Review of 16 Studies. Work & Stress, 20, 316-334. http://dx.doi.org/10.1080/02678370601065893
[51]	Thomas, M. R., Dyrbye, L. N., Huntington, J. L., Lawson, K. L., Novotny, P. J., Sloan, J. A., & Shanafelt, T. D. (2007). How Do Distress and Well-Being Relate to Medical Student Empathy? A Multicenter Study. Journal of General Internal Medicine, 22, 177-183. http://dx.doi.org/10.1007/s11606-006-0039-6
[52]	Tucker, L. R., & Lewis, C. (1973). A Reliability Coefficient for Maximum Likelihood Factor Analysis. Psychometrika, 38, 1-10. http://dx.doi.org/10.1007/BF02291170
[53]	Tyssen, R., Vaglum, P., Gr?nvold, N. T., & Ekeberg, ?. (2005). The Relative Importance of Individual and Organizational Factors for the Prevention of Job Stress during Internship: A Nationwide and Prospective Study. Medical Teacher, 27, 726-731. http://dx.doi.org/10.1080/01421590500314561
[54]	WFME (2003). Basic Medical Education. WFME Global Standards for Quality Improvement. Copenhagen: WFME.
[55]	White, C., Bradley, E., Martindale, J., Roy, P., Patel, K., Yoon, M., & Worden, M. K. (2014). Why Are Medical Students ‘Checking out’ of Active Learning in a New Curriculum? Medical Education, 48, 315-324. http://dx.doi.org/10.1111/medu.12356
[56]	Wolf, T. M., Balson, P. M., Faucett, J. M., & Randall, H. M. (1989). A Retrospective Study of Attitude Change during Medical Education. Medical Education, 23, 19-23. http://dx.doi.org/10.1111/j.1365-2923.1989.tb00807.x
[57]	Wolf, T. M., Faucett, J. M., Randall, H. M., & Balson, P. M. (1988). Graduating Medical Students’ Ratings of Stresses, Pleasures, and Coping Strategies. Journal of Medical Education, 63, 636-642.